We at Food 4 Success, LLC understand that protected health information about you and your health is personal. We are committed to protecting health information about you. This Notice applies to all records of your care generated by Food 4 Success, LLC whether made by Food 4 Success, LLC personnel or your personal doctor.

This Notice will tell you about the ways in which we may use or disclose protected health information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of protected health information. Federal law requires us to:

Make sure that protected health information that identifies you is kept private;

Notify you about how we protect protected health information about you;

Explain how, when, and why we use and disclose protected health information; and

Follow the terms of the Notice that is currently in effect.

We are required to follow the procedures in this Notice. We reserve the right to change the terms of this Notice and to make new Notice provisions effective for all protected health information that we maintain by:

Posting the revised Notice in our office;

Making copies of the revised Notice available upon request; and

Posting the revised Notice on our Web site.

HOW WE MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION ABOUT YOU

The following categories describe different ways that we may use and disclose protected health information without your written authorization.

For Treatment. We may use protected health information about you to provide you with, coordinate, or manage your medical treatment or services. We may disclose protected health information about you to doctors, nurses, technicians, medical students, or other Food 4 Success, LLC personnel, including persons outside of our office who are involved in your medical care.

Food 4 Success, LLC staff may also share protected health information about you in order to coordinate your care for such reasons as prescriptions, lab work, and x-rays.

We may use and disclose protected health information to contact you as a reminder that you have an appointment for treatment or medical care at Food 4 Success, LLC. We may use and disclose protected health information to tell you about or recommend possible treatment options, treatment alternatives, or health-related benefits or services that may be of interest to you.

For Payment for Services. We may use and disclose protected health information about you so that the treatment and services you receive at Food 4 Success, LLC may be billed to and payment may be collected from you, an insurance company, or a third party. For example, we may need to give your health plan information about nutrition services you received at Food 4 Success, LLC so your health plan will pay us or reimburse you for the service. We may also tell your health plan about the nutrition services you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

For Health Care Operations. We may use and disclose protected health information about you for Food 4 Success, LLC health care operations, such as our quality assessment and improvement activities, case management, coordination of care, business planning, customer service, and other activities. These uses and disclosures are necessary to run the facility, reduce health care costs, and make sure that all of our patients receive quality care.

For example, we may use protected health information to review our treatment and services or to evaluate the performance of the dietitian who is providing your services. We may also combine protected health information about many Food 4 Success, LLC patients to decide what additional services Food 4 Success, LLC should offer, what services are not needed, and whether certain treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and other Food 4 Success, LLC personnel for review and learning purposes.

Subject to applicable state law, the law allows or requires us to use or disclose your health information without your authorization in some limited situations for purposes beyond treatment, payment, and operations.

As Required by Law. We will disclose protected health information about you when required to do so by federal, state, or local law.

Research. We may disclose your protected health information to researchers when their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your information. We may permit researchers to review records to help identify patients who may be included in their research projects or for similar purposes as long as the researchers do not remove or take a copy of any health information.

To Avert a Serious Threat to Health or Safety. We may use and disclose protected health information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

We may also disclose protected health information about you to a government authority if we reasonably believe that you are a victim of abuse, neglect, or domestic violence. We will only disclose this type of information to the extent required by law, and we will only disclose it if (a) you agree to the disclosure, or (b) the disclosure is allowed by law and we believe it is necessary to prevent or lessen a serious and imminent threat to you or another person.

Judicial and Administrative Proceedings. We may disclose your protected health information in response to a court or administrative order. We may also disclose your protected health information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made, either by us or the requesting party, to tell you about the request or to obtain an order protecting the information requested.

Business Associates. We may disclose information to business associates who perform services on our behalf (such as billing companies). However, we require that these associates appropriately safeguard your information. Our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

Public Health. As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Health Oversight Activities. We may disclose protected health information to a health oversight agency for activities authorized by law. These activities include audits, investigations, and inspections, as necessary for licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Law Enforcement. We may release protected health information as required by law, or in response to an order or warrant of a court, a subpoena, or an administrative request. We may also disclose protected health information in response to a request related to identification or location of an individual, a victim of crime, a decedent, or a crime on the premises.

Organ and Tissue Donation. If you are an organ donor, we may release protected health information to an organ donation bank or to organizations that handle organ procurement or organ, eye, or tissue transplantation, as necessary to facilitate organ or tissue donation and transplantation.

Special Government Functions. If you are a member of the armed forces, we may release protected health information about you if it relates to military and veterans activities. We may also release your protected health information for national security and intelligence purposes, protective services for the President, and medical suitability or determinations made by the Department of State.

Coroners, Medical Examiners, and Funeral Directors. We may release protected health information to a coroner or medical examiner. This release may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose protected health information to funeral directors, consistent with applicable laws, to enable them to carry out their duties.

Correctional Institutions and Other Law Enforcement Custodial Situations. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release protected health information about you to the correctional institution or law enforcement official as necessary for your or another person’s health and safety.

Worker’s Compensation. We may disclose protected health information as necessary to comply with laws relating to worker’s compensation or other similar programs established by law.

Food and Drug Administration (FDA). We may disclose to the FDA, or persons under the jurisdiction of the FDA, protected health information relative to adverse events with respect to drugs, foods, supplements, products, and product defects, or postmarketing surveillance information to enable product recalls, repairs, or replacement.

Fundraising. We may also contact you as part of fundraising efforts. You have the right to opt out of receiving such communications.

YOU CAN OBJECT TO CERTAIN USES AND DISCLOSURES

Unless you object, or request that only a limited amount or type of information be shared, we may use or disclose protected health information about you in the following circumstances:

We may share with a family member, relative, friend or other person identified by you protected health information that is directly relevant to that person’s involvement in your care or payment for your care. We may also share information to notify these individuals of your location, general condition, or death.

We may share protected health information with a public or private agency (such as the American Red Cross) for disaster relief purposes. Even if you object, we may still share this information if necessary under emergency circumstances.

If you would like to object to use and disclosure of protected health information in these circumstances, please call or write to the contact person listed on page 1 of this Notice.

YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION ABOUT YOU

You have the following rights regarding protected health information that we maintain about you:

Right to Inspect and Copy. You have the right to inspect and copy protected health information that may be used to make decisions about your care or payment for your care. If we maintain your protected health information electronically, you can request that we provide access in an electronic form and format that is readily producible, or in a form and format agreed to by us.

To inspect and copy protected health information that may be used to make decisions about you, you must submit your request in writing to Elissa Lueckemeyer RD, LD. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or supplies associated with your request. We may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any other state or federal needs-based benefit program. We will respond to your request no later than 30 days after we receive it. There are certain situations in which we are not required to comply with your request. In these circumstances, we will respond to you in writing, stating why we will not grant your request and describe any rights you may have to request a review of our denial.

Right to Amend. If you feel that protected health information we have about you is incorrect or incomplete, you may ask us to amend or supplement the information.

To request an amendment, your request must be made in writing and submitted to Elissa Lueckemeyer RD, LD. In addition, you must provide a reason that supports your request. We will act on your request for an amendment no later than 60 days after we receive it.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In these circumstances, we will provide a written denial stating why we will not grant your request. In addition, we may deny your request if you ask us to amend information that:

Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;

Is not part of the protected health information kept by [list clinic name];

Is not part of the information that you would be permitted to inspect and copy; or

We believe is accurate and complete.

Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of protected health information about you.

To request this list of disclosures, you must submit your request in writing to Elissa Lueckemeyer RD, LD. You may ask for disclosures made within the six years before your request. The first list you request within a 12-month period will be free. For additional lists in that 12-month period, we may charge you for the costs of providing the list. We are required to provide a list of all disclosures except the following:

Disclosures made for your treatment;

Those used for billing and collection of payment for your treatment;

Those related to health care operations;

Those made to you or requested by you, or those that you authorized;

Those that occurred as a byproduct of permitted use and disclosures;

Those used for national security or intelligence purposes, or provided to correctional institutions or law enforcement regarding inmates;

Those that were a part of a limited data set of information that does not contain information identifying you.

Right to Request Restrictions. You have the right to request a restriction or limitation on the protected health information we use or disclose about you for treatment, payment, or health care operations, or to persons involved in your care.

We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment, the disclosure is to the Secretary of the Department of Health and Human Services, or the disclosure is required by law. .

To request restrictions, you must make your request in writing to Elissa Lueckemeyer RD, LD.

Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.

To request confidential communications, you must make your request in writing to Elissa Lueckemeyer RD, LD. We will accommodate all reasonable requests.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice at any time. To receive a paper copy, contact Elissa Lueckemeyer RD, LD.

Right to Receive Notice of Breach. You have a right to be notified upon a breach of any of your unsecured protected health information.

Rights for Out-of-Pocket Payments. If you paid out of pocket in full for a specific item or service, you have a right to ask that your protected health information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations. We are required to agree to your request unless the disclosure is otherwise required by law.

TYPES OF USES AND DISCLOSURES REQUIRING AN AUTHORIZATION

Most uses and disclosures of psychotherapy notes require us to obtain an authorization from you. In addition, in most instances, we cannot use or disclose your protected health information for marketing purposes or sell your protected health information without your written authorization. Finally, any other use or disclosure not described in this Notice will be made only with your authorization. Any time you provide us with a written authorization, you may revoke it any time in writing, to the extent that we have not already taken action in reliance on your previous authorization.

OTHER USES AND DISCLOSURES

We will obtain your written authorization before using or disclosing your protected health information for purposes other than those described in this Notice (or as otherwise permitted or required by law). You may revoke this authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your information, except to the extent that we have already taken action in reliance on the authorization.

YOU MAY FILE A COMPLAINT ABOUT OUR PRIVACY PRACTICES

If you believe your privacy rights have been violated, you may file a complaint with Elissa Lueckemeyer RD, LD or file a written complaint with the Secretary of the Department of Health and Human Services. A complaint to the Secretary should be filed within180 days of the occurrence or action that is the subject of the complaint.

If you file a complaint, we will not take any action against you or change our treatment of you in any way.

CHANGES TO THIS NOTICE

We reserve the right to change this Notice and make the new Notice apply to health information we already have, as well as any information we receive in the future. We will post a copy of our current Notice in our office. The notice will have the effective date clearly marked at the top of the first page.